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Why is the mortality rate for COVID ICU patients in the Awake and Walking ICU less than half of the other COVID ICUs in the same hospital system in the same community? How have sedation and mobility practices impacted rates of central lines, vasopressor use, paralysis, tracheostomies, and LTACH admissions? How has this ICU continued to keep COVID patients awake and mobile during this pandemic? Dr. Joel Pittman shares with us valuable updates from the Awake and Walking ICU.

Episode Transcription

Kali Dayton 0:00
Okay, I have received a lot of questions about how the “Awake walking COVID icu has fared. Jeff, one of the respiratory therapists addressed a lot of their COVID practices in Episode 86. This episode, Dr. Joe Pittman shares with us some big picture outcomes and successes that are attributable to the persistent practice of avoidance station and prompt ambulation. even and especially during COVID-19. Dr. Pittman, thank you so much for coming on the podcast. Do you mind introducing yourself?

Dr. Joel Pittman 1:08
Of course, thank you for having me. My name is Joel Pittman, I practice Pulmonary and Critical Care Medicine. I’m originally from Detroit, Michigan, I went to medical school at Wayne State University in Detroit, which was a wonderful place to learn medicine. I then did my residency and fellowship at the University of Utah, in internal medicine, and then pulmonary critical care. After my fellowship in 2010, I went into private practice for a few years. And then I’ve been at my current job for about the last seven years.

Kali Dayton 1:56
So what was it like after all of that training outside hospitals to come to the awakened walk in ICU? What kind of experience was that initially?

Dr. Joel Pittman 2:06
Yeah, so luckily, my training involves being in and around the awake and walking ICU. So it wasn’t a huge surprise to see what was happening in this ICU with sedation and mobility. However, it was vastly, vastly different than the eight or 10 ICUs. I had spent time in prior to prior to the job.

Kali Dayton 2:39
I remember you talking about tricky ostomies at one point. And as a new nurse that was so unique to me, we didn’t we didn’t really do a lot of tricky ostomies in that ICU, and you’d mentioned how frequently you were doing them and then you came to the wake and walk in ICU and it just stopped essentially

Dr. Joel Pittman 2:55
correct. In my private practice job. I was in a practice in an ICU, that essentially the only way to awaken a patient was to place a tracheostomy. These patients were otherwise completely sedated for days and days and days. And and again, the only way to wake them up safely and comfortably for the staff was to place tracheostomy, so a lot of tracheostomy is were performed in in this particular ICU.

Kali Dayton 3:32
And that was in the like around 2010. I’m trying to think what the timing would have been.

Dr. Joel Pittman 3:38
Yeah, so 2010 to 2013, or 14.

Kali Dayton 3:43
And that’s still the standard practice around the country in the world is that this cultural belief that patients have to be sedated until they receive a tracheostomy because of unknown reasons. It’s safer to wake patients up once they have a hole in their throat. So that’s we’re still stuck in that routine. And yet, and they wake and walk in ICU, they wake up right away and are mobile and don’t and usually end up with tracheostomy is. So for years, we practice this way and then COVID Hit how have you seen COVID affect the process of care in this ICU.

Dr. Joel Pittman 4:20
It hasn’t much affected of lack of sedation and mobility. We are seeing more patients with respiratory failure on the ventilator, including patients who are have maximum settings on the ventilator. And because of our culture and and our experience, we are still awakening patients despite their profound respiratory failure.

Kali Dayton 4:52
Which is probably really mind blowing to a lot of people if I post things online. The comments always say Well, clearly that pigs Patient in that picture doesn’t have a peep of 14 and 70%. And I’ll say no, they have a peep of 18 and 100% Smiling with a thumbs up on it walking. But that’s a really scary prospect. But you’ve seen good outcomes, even during COVID.

Dr. Joel Pittman 5:16
Yes, we have traveling nurses because of how because of the pandemic and how in dire straits, we are for staffing, we have travelers come in and simply don’t believe what’s happening. They they’ve made comments directly to me how much they appreciate working in this particular ICU because people actually survive COVID and are getting better. So so it is a what we do with sedation mobility works well, in very sick COVID patients.

Kali Dayton 5:54
And the more I studied the research as far as the role immobility plays, and exacerbating the neutrophilic, response, and alongs, and things like that, it makes so much sense. And this hospital is part of a multi hospital system. And it’s one of the main COVID centers in that area. How have the outcomes compared to the other ICUs or COVID units in the area?

Dr. Joel Pittman 6:19
Yeah, so I’m told very favorably, our CMO has louded us who work in our particular ICU on our outcomes. He tells me that our mortality is half of what other ICUs in the enterprise are reportedly, roughly, we have a roughly 20% mortality in intubated COVID patients where we’re seeing about a 40% mortality across our enterprise. We are thankfully a very integrated enterprise. We certainly within our ICUs we perform mechanical ventilation the same, our treatments for COVID are all the same. So I’d argue that it’s probably sedation and mobility that are key to improving mortality.

Kali Dayton 7:23
Yeah, I really hope we’re able to do data collection and do kind of a retrospective study on this because when else have we had the exact same ailment, this exact same population in the same community with essentially the same treatments except for sedation and mobility? That’s really powerful. And I know that the team has been really demoralized because of staffing crisis, a lot of frustration that lost a lot of staff still 20% mortality is much higher than what we’re used to there. And they’ve had staffing ratios that are have been inappropriate, three patients to one nurse. I mean, it’s been really difficult.

I think the assumption is made that this ICU has this success because they have one to one staffing ratios. A lot of people assume that that’s the only way you can keep a patient awake on a ventilator. Do you see high risks? Is the safety? Is it really unsafe to have patients awake on the ventilator even during COVID? Are the delirium rates that high?

Dr. Joel Pittman 8:21
So, let me answer your first question. I think it is safe to have patients awake and alert and walking. There are, I think, it’s slightly less safe, given some barriers specific to COVID, that are negative pressure rooms with our doors being closed all the time can pose a risk in terms of not being able to get to a patient safely and quickly if if they are start pulling at things inappropriately. But ultimately, these people have respiratory failure and are on our ventilator. And we feel strongly that that keeping these people, these these people awake, and alert and interactive and pro active. Oh, benefit is the right thing to do.

Kali Dayton 9:21
Absolutely. And I think a lot of the discussion outside of this ICU is this question of safety. It’s unsafe to have patience and restraint. But yet, when we’re talking about safety, we’re not factoring in all the unsafe risks of patient and immobility, how unsafe delirium is how unsafe it is to let patients atrophy and increase the risk of mortality just with that alone. So I think this is a good case study, or a good example of how we actually improve safety when we avoid sedation, and don’t chemically restrain people and my parents has a lot of patients in that ICU can be unrestrained because they are not delirious. So I think we try to drive down right Straight use with sedation use, and yet it’s a little backwards.

Dr. Joel Pittman 10:05
Yeah, I agree. But if people if people patients sick with COVID are awake and interactive and not delirious, they often are safer and are happy to do what we ask of them. And our understand that they’re into tracheal tube is a life saving piece of equipment that needs to stay in place. So they they often can, I’m often seeing patients adjust their endotracheal tube a little uncomfortable without pulling it.

I have one of my favorite patients was a young woman with COVID pneumonia, who had profound respiratory failure. And she was on a peep of a team and with an F out to 100%. And she required proning. And she was happy to be awake and alert and help herself prone as well as as well as interact with her family by texting and FaceTiming. While she was prone and and and and while it took a long time based on the severity of her her ARDS pneumonia, she eventually walked out of our units, I’d say I think it took three or four weeks of her being in our ICU.

Kali Dayton 11:44
Which is a long time for that ICU, right? Most COVID, even COVID patients don’t stay three or four weeks?

Dr. Joel Pittman 11:49
It’s not out of the it’s not off the curve in terms of our experience with severe COVID pneumonia, we’re seeing patients spend, I think our average is about 10 days on a ventilator. So it’s a long, it’s a long a long sickness, that that is benefited by patients being awake and alert throughout it and and and and serves them well. When they do get better.

Kali Dayton 12:24
So I think a lot of them, maybe national norm is have patients on the ventilator for three four weeks before they get traped and Sentinelle. Tak mean that is the norm, let alone have someone successfully X debated after such high ventilator settings, and then walk out the door that might be unfathomable to most people and then to have them preowned and awake and communicating without paralytics.

I think it sounds like we’re very quickly paralyzing patients and deeply sedated them automatically, which I think is that one comes before the other I think we deeply sedate them. And then that probably causes some level of ventilator dyssynchrony. And so we instinctively paralyze them. How often are you guys using paralytics? And how, what’s kind of your proning protocol?

Dr. Joel Pittman 13:08
So we have patients sick enough and uncomfortable enough on the ventilator that we do that do require sedation and paralysis. I’d argue those those patients are a significant minority. Even if a patient requires sedation and paralysis on day one or two of their ICU stay, we still make an effort to do a full sedation vacation when they are supine.

And oftentimes we find that that deep sedation is unnecessary. And deep sedation to us is usually a propofol and fentanyl infusion. And we discover that a fentanyl infusion at most or fentanyl boluses. alone can keep a patient comfortable on a ventilator with pro profound or severe respiratory failure.

Kali Dayton 14:18
Have you ever used midazolam on any of these patients?

Dr. Joel Pittman 14:22
No.

Kali Dayton 14:24
That has been very standard. It’s new….The new hot trend right now for everyone to be on midazolam, propofol, fentanyl and often precedex on top of it. It’s discouraging to see how much benzodiazipines have come back. But the way you walk in ICU has treated probably hundreds 1000s of COVID patients now and never use midazolam.

And I remember the very beginning. We had to send out educational material to talk about sedation vacations because we weren’t doing them beforehand because we didn’t really sedate patients. So we had to teach everyone how to do a sedation vacation and it was nice to see it used so appropriately. When I learned sedation vacations as a travel nurse back in 2014, it was just turned on the propofol, just enough to see them thrash, then crank it back up. Yet, that’s how they do at this “Awake and Walking ICU”. I mean, what if someone’s supine, so they’re prone and they can’t oxygen maybe in supine, that it’s not time for sedation vacation yet. But once they’re supine, and then we do a sedation vacation, they really want to see if they can oxygenate with movement. Right? There’s no need to turn it back on.

Dr. Joel Pittman 15:27
Correct? Yeah, John Cress’s elegant, a small but elegant sedation vacation paper, which I think is close to 20 years old. In my experience, it has never been done well, in a clinical setting. And again, oftentimes, in our ICU, sedation vacations aren’t even necessary.

Kali Dayton 15:55
Which is just so encouraging, and it’s really easier to do it, do it right at the very beginning, at the front end, so you don’t have to do the cleanup at the back end and fix those things. I see a lot of teams talking about how difficult it is to implement the ABCDEF bundle. But I think that is difficult to implement, I think it is the way that they’re implementing it.

Which means that with this assumption that sedation is automatically started on every patient on mechanical ventilation. And then we do a sedation vacation later. Oftentimes, the parameters are set once the ventilator settings are peep of eight and fi02 is less than 60%. So you can’t do a vacation until those parameters are set hit. And now you’ve created delirium, and now it’s down to the nurse to wrestle a patient their whole shift with delirium because they’re doing a vacation or the vacations just aren’t done or they’re done poorly.

It is really difficult to standardize. Whereas the waking walk in ICU, the standardization is to avoid sedation and prevent delirium. And that’s really foreign to a lot of listeners. And I think the listeners on the podcast are wanting to transition to that. What experience or what advice would you give to teams that are wanting to transition to this process of care?

Dr. Joel Pittman 17:10
It’s a great question, critically important question. And it ultimately comes down to culture that culture requires time, and energy, and resources. And it is very much very much that culture very much involves a team effort. So that places a patient’s interaction at patient places a patient’s ability to be awake, and proactive in their care at the top of the priority list, despite how sick a patient is and for whatever they come in with having them be awake and interactive.

And walking as soon as possible is is the priority within our culture. It takes a team effort, nurses, techs, respiratory therapists, and physical therapists are on the frontline of that they do the brunt of the work to make it happen. And oftentimes our advanced practice practitioners are involved and once in a while a physician gets involved but but it’s it’s it’s the it’s the nurse tech, respiratory therapist and physical therapist who do do the majority of the work.

It’s easy once that culture is in place, because you see what a huge difference it makes in a patient in a person’s a person who was critically ill. It makes a huge difference in their life, really. And as a physician, easily one of the most satisfying things that happens in our ICU and to our for our patients, we do a lot of exciting life saving procedures and resuscitations, but when you see a patient awake and walking and trying to do their part to make themselves better, there’s there’s there’s little more satisfying than that.

Kali Dayton 19:43
Absolutely. And a lot of people reaching out to me for the webinars and presentations are nurses, physical therapists people on that level of the bedside. But sometimes they report they have a hard time getting physician buy in what recommendations which you give to those visionaries, those ICU evolutionists wanting to bring the change to their teams, how can they incorporate the full team?

Dr. Joel Pittman 20:11
Certainly don’t get in the way of someone, someone with a vision who wants to to enact those changes certainly don’t get in the way, read the literature about post ICU syndrome and how terrible it can be and try and do everything that you can to avoid the post ICU syndrome.

Kali Dayton 20:36
What do you envision for the future Critical Care Medicine?

Dr. Joel Pittman 20:40
What I’ve noticed over my career is that we are doing things in a less invasive way and trying to keep things as normal for a person who is critically ill as possible. And one example is the PA catheter. The PA catheter was used frequently at the beginning of my training, and now we’re using echo to get some of the information that of PA catheter was so so a less invasive way to get information about a patient’s cardiac status and volume status, mechanical ventilation using low lower tidal volumes, because that is probably that’s more physiologic, that’s more normal than then using larger tidal volumes, getting away with using peripheral IVs.

To, to to to infuse vasopressors, rather than a central line if it’s appropriate, and keeping people awake. And interactive, is just a natural progression of trying to keep people as normal as possible to ultimately get them better from their critical illness and get them back on their feet. And to avoid the post ICU syndrome.

Kali Dayton 22:20
That’s a wait great way to capture this movement, humanizing the ICU, to allow our patients to be human and as normal as possible, all the movements towards normal sleep cycles. Not to regress, but you mentioned central lines. How often are your COVID patients having central lines? Is it everyone like in other units?

Dr. Joel Pittman 22:40
Not everyone. Not everyone, I don’t know exactly the percentage, but it’s far from everyone. The sickest ones who require proning usually are getting a central line to ensure to ensure a vascular access that won’t get pulled in, in the process of pruning. So I’d argue, at most 50% of our COVID patients are getting getting central line.

Kali Dayton 23:10
Which that alone is probably unfathomable to a lot of clinicians, when we automatically start sedation on every patient mechanical ventilation, then you can just count on hypotension. And you’re going to need vasopressors for an extended period of time. And so it seems like every patient gets intubated, sedated to the central line. And that has to be a huge contributor to these hospital acquired infection risks that we have.

Even independent of the ventilator associated pneumonia as but the central line infections have to be so much higher than usual because of the rates in which we’re giving central lines. And it’s a little discouraging to think that they maybe are preventable. If we did evidence based practices without sedation practices, we could prevent a lot of infections. So that’s it’s an interesting side note that less than 50% Probably have central lines, because avoiding sedation. And a lot of teams are reporting that a lot of patients are on CRT for COVID. How often are you seeing CRRT?

Dr. Joel Pittman 24:19
More often than before COVID Too often in general, but I don’t have exact numbers, but I’d argue somewhere between a third 25% And a third of our patients are requiring at most are requiring the CRRT.

Kali Dayton 24:40
Yeah, it’d be interesting. Hopefully someday we can go back and have the numbers but that’s just an interesting insight because we know that as muscular atrophy, we pour fuel on this inflammatory process and we contribute to multi organ failure. And so it’d be interesting to try to dissect how much of a benefit this was to sparing the kidneys as well as the other organs by implementing early mobility, actual early mobility. Well, this has been so beneficial. Thank you so much for sharing all of your experience. Thanks for all your good work. Is there anything else you would share with the ICU community?

Dr. Joel Pittman 25:14
I, I’ve never been critically ill thank God. So I have no idea what our patients are experiencing. But I feel that keeping people awake and interactive and participating in their care preserves human dignity, I can only imagine how vulnerable and scared our critically ill patients are. And, and, and I, again, I think keeping people awake, and alert and interactive is one, if not the most important thing that we can do for our patients.

Kali Dayton 26:01
I absolutely agree. And I think there’s a new movement with ICU survivors and ICU clinicians, in which they’re making themselves a DNS do not sedate. In episode three, I interviewed Susan East who had had it the normal way her first time with ARDS and her following two times with ARDS, she was awake. And her experience was wholly different. And she talks about the dignity part of it, how she wanted to have her own autonomy, call her on shots, interact with her family, and I am so grateful that that’s what we can do for patients.

I think part of our burnout throughout the community is the dehumanization of our patient care, we all got into this to save lives, to connect with people to love people care for them provide the best care. And that’s all been stripped from us during COVID. And especially with our practices that have now gone back 1015 years and time. And so I think that’ll be part of the healing process is to re humanize the ICU, to see our patients as human to get to know them to look in their eyes, to interact with them, communicate with them and actually see them get better and walk out the doors and to know that we facilitated that we actually did save their lives in that moment, but also their quality of life for the rest of their lives. And that will is what’s going to keep us in critical care medicine and help put it into this mass exodus. Dr. Pittman. Thank you so much. Appreciate it.

Dr. Joel Pittman 27:24
Thank you again.

Transcribed by https://otter.ai

 

 

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